Podcast: Why Centralizing UR Makes Even More Sense Now

Steve Wright:

Welcome to another edition of the ongoing Optum360 podcast series on topics related to hospital utilization review. I'm Steve Wright, a marketing director for Optum360, and our topic on this episode delves into why centralizing utilization review makes even more sense now. In many hospital organizations, utilization review functions are siloed by facility. But how can centralizing the UR function provide value? I'm joined today by Tabitha Hapeman, Manager of the Resource Management Center and Patient Financial services at Sentara healthcare. Welcome Tabitha.

Tabitha Hapeman:

Thank you guys so much for having me.

Steve Wright:

Okay. Let's get started. Tabitha, tell me a bit about your current role.

Tabitha Hapeman:

Sure. I currently manage both the Patient Financial Services department and the Resource Management Center for Sentara Healthcare. Patient Financial Services is responsible for insurance verification eligibility and the resource management center is responsible for authorization obtainment from commercial payers, and ensuring compliance with CMS regulations related to UR. So I manage the gamut from the insurance verification eligibility to authorization obtainment for the systems for hospitals.

Steve Wright:

And can you also briefly tell us about your organization?

Tabitha Hapeman:

Certainly. Sentara Healthcare is a 12-hospital system. We are located in Virginia in the Northern part of North Carolina. We're an integrated healthcare system with over 2,500 acute care beds across those 12 sites. We've got four medical groups with over 3,800 medical providers, and we also have a health plan in the form of Optima Insurance. And of course we've got post-discharge services such as home care and hospice.

Steve Wright:

Okay Tabitha, let's jump right into the heart of the topic here. How does centralizing UR provide value in the current pandemic climate or any crisis situation?

Tabitha Hapeman:

That's certainly a timely question. I think everyone in healthcare knows, especially now, that ensuring healthy margins is more important than ever. So of course every organization wants to be appropriately reimbursed for their services and to ensure that their revenue is preserved, meaning safe from future audits and take backs. But recently we've seen that hospitals can experience financial crises, even in the midst of a pandemic. So centralized utilization review allows for maximum efficiency and effectiveness of process. Meaning hospitals should be able to ensure appropriate reimbursement and to have confidence that those dollars are safe from future audits. So while there are certainly some challenges with the centralized utilization review process, such as the potential for furlough or the need to quickly pivot to other projects, or even back to the bedside, the central design ensures reimbursement and compliance.

               So I think we'd all agree that commercial payers have given us some leeway during this time, but they've not suspended the need to prove medical necessity or obtain authorizations. So those patients undergoing things like need-planned surgeries still have to have prior offs to their procedure. And while most hospitals have paused elective surgeries, we've not paused life-sustaining surgeries such as cardiac procedures. And those patients still have to have authorizations in place and typically clinical provider to the payer post-bedding after they have their procedure. And then lastly, while CMS has said that hospitals can waive the UR process during this crisis if they need to, they've not said that hospitals can waive the burden of sending accurate claims. So even for CMS who's been very flexible and supportive during this time, there's still the need to ensure accurate and appropriate claims and that's accomplished by a healthy UR process.

Steve Wright:

Good timely advice, Tabitha. So why would centralizing utilization review make sense for an organization like yours regardless of the COVID-19 crisis?

Tabitha Hapeman:

Another great question. As our system grew, it became really apparent that maintaining standardization and systemness was really not possible if each site was conducting utilization review practices independently. There was a lot of discussion around centralizing utilization review within the system years before it actually occurred. And there were a few things that needed to happen first, such as transitioning all the sites to an electronic medical record. So once the system was comprised of four or five hospitals, and there were more mergers and acquisitions planned, and those sites had all transitioned to the new EMR, then the decision was made that now we were in a place that we could centralize this process.

               Centralization makes so much sense for systems that want a standardized process for UR. Payers become more challenging to obtain authorizations from every year, and the system knew that tracking that behavior and centralizing the knowledge in one department would allow us to keep up with those continuing changes in demand. And then on the CMS side of course, you have to make sure that the process supports the conditions of participation and you have to ensure compliance. And it's difficult to ensure a complainant process if that process is being performed in multiple sites with different leaders. So ultimately for all those reasons, the centralized utilization review department was launched in 2013.

Steve Wright:

Can you tell me a little bit more about the before and after view of your own experience centralizing UR at your organization?

Tabitha Hapeman:

Sure. Before centralization of UR, all the utilization review was conducted by the bedside case managers. So the case managers in the hospital were really Jack of all trades and they did everything from discharge planning to authorization obtainment, conditions of participation compliance, and social determinants of health management. And that's a tall order. So what tends to happen, at least in my experience, is that case managers will more on one thing than the other. And people tend to focus on what they enjoy most. So if their passion is for assessing patients and ensuring needs are met post discharge, then that's what that case manager is naturally going to focus on, and that may mean an authorization obtainment takes a back seat.

               So once the centralization took place, the department was shifted to being payer-based. So that meant that we were able to specialize based on certain payers, such as Medicare, Humana, Anthem, et cetera. And this allowed case managers not only to gain a level of expertise in utilization review in general, but expertise in particular processes, as all payers are a little bit different. And ultimately that led to increased efficiency. Meaning our UR case managers can complete more cases in a single day. They're also able to very quickly identify pair behaviors, which needed to be escalated. So we were able to build much stronger relationships with contracting over the past few years, which has been so critical.

Steve Wright:

Sounds like a lot of positives for your own experience, but how do you assess the readiness of an organization in order to make this move?

Tabitha Hapeman:

Certainly. So absolutely a lot of positives, but there is quite an assessment that needs to occur prior to this monumental shift to centralization. First, if you're going to centralize, especially for multiple sites, you have to have software system alignment. So having all sites on the same EMR is obviously crucial. If a single site is going to centralize, it's certainly easier if that site has an EMR, which I think the vast majority of hospitals do have now. Centralizing with paper charting, I think would be rather challenging. Beyond the EMR though, the system needs to assess its readiness to adjust or adopt utilization review specific software. So ensuring UR case management has an appropriate tool to document, communicate with payers, et cetera, is really important. And our system, we changed software systems in 2018, and while both our prior system and our current system had pros and cons, we really wanted to ensure that we had a tool to work within, and that was a vital to standardizing the process.

               I think everyone would agree that paper notes and faxes are less than ideal. Once that infrastructure as it was developed, then the system needs to assess staffing. And that's always a challenge. My recommendation for any system assessing resource needs, is to break it down by payer and then determine how acute each payer is. And what I mean by that is that certain payers, let's say Humana or infant Medicaid replacement products might require more resources than other payers. So ensuring your business case is accurate as possible based on your payer mix, for your specific system is very important. A blanket statement of something like, "Case managers can work 20 cases a day." May lead to inappropriate staffing models in the beginning.

Steve Wright:

So if an organization has made this decision, they've assessed their readiness and they're moving forward, what can they expect as the biggest hurdles to success moving forward?

Tabitha Hapeman:

I think for us, we just didn't know what we didn't know when we first started out. Our department has evolved quite a bit in the past seven years. We've assessed, reassessed and change things constantly to ensure we're keeping up with payers, the landscape of healthcare and implementing practices we've discovered are most effective. So when implementing something which was radically different or changing course in a significant way, you have to ensure you have leaders focused on constantly reassessing the project. There's no way to predict where each pothole is going to be when you first start out, and you're guaranteed to hit a few of them as you're centralizing and launching this.

               And then I think another big hurdle is communicating to key leaders in the system what the centralized UR department does and why it's critical. UR is such a behind the scenes kind of department. We're not the kind of department that is center stage, if you will. And that can mean it's difficult to quantify the value that that department adds to the system. So ensuring leaders are well versed in communicating the importance of UR in general, is key to sustaining the department.

Steve Wright:

Okay. One last question, Tabitha, what has been the most impactful, positive results of this centralization project?

Tabitha Hapeman:

That's a great question to end on. We have absolutely landed upon best practice in a number of areas. We have fine-tuned our process for each payer, including how we handle concurrent denials, how and what we communicate with payers and so on. We also have a very compliant process. We really pride ourselves on being part of the backbone of compliance within the clinical revenue cycle. We feel very strongly that it's our responsibility to make sure patients are in the right status, and the system receives the appropriate reimbursement for the care we're providing. So we want to ensure clean and appropriate dollars are coming into the system in order to support the Sentara mission of we improve health every day.

Steve Wright:

Great. That's all we have for today. Thanks Tabitha for sharing your perspective and expertise, and I hope this has been helpful for our listeners. Please be on the lookout for additional episodes of our podcast and thanks to our listeners for their commitment to make healthcare better for everyone.